Every finding on record at Hammonds Lane Center

Based on record review and interviews, it was determined that the facility failed to administer and document medications in accordance with professional standards. This was evident for 1 (Resident #103) out of 4 residents reviewed for medication administration.The findings include:On 8/6/2026 at 9:35 AM, a review of Complaint 2601591 and interview with the complainant was conducted. The complainant alleged the facility failed to follow medication orders and monitor Resident #103 appropriately.On 8/6/2026 at 9:54 AM, a review of Resident #103's orders was conducted. Resident #103 was ordered the following medications in the month of August in 2025; Morphine Sulfate (an opioid pain relief medication) oral Solution 100 MG/5ML 0.5 ml by mouth every 4 hours for pain/dyspnea, Morphine Sulfate oral Solution 100 MG/5ML 1 ml by mouth every 4 hours for pain/dyspnea, Morphine Sulfate oral Solution 100 MG/5ML 0.75 ml by mouth every 4 hours for pain/dyspnea, Lorazepam (an antianxiety medication) oral Tablet 1 MG 1 tablet by mouth every 4 hours for anxiety, and Lorazepam oral Concentrate 2 MG/ML 0.5 ml by mouth every 4 hours for Shortness of breath/anxiety.On 8/6/2026 at 11:14 AM, a review of Resident #103's Medication Administration Audit Report for the month of August was conducted. A report for medication administrations documented over 1 hour late in the month of August 2025 revealed:Morphine Sulfate oral Solution 100 MG/5ML 0.5 ml was administered late 15 timesMorphine Sulfate oral Solution 100 MG/5ML 1 ml was administered late 8 timesMorphine Sulfate oral Solution 100 MG/5ML 0.75 ml was administered late 3 timesLorazepam 1 mg oral tablet by mouth was administered late 2 timesLorazepam Oral Concentrate 2 MG/ML 0.5 ml was administered late 3 timesThe late administrations were documented by multiple nurses.On 8/6/2026 at 11:45 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that the expectation for the nursing staff was to give and document the medications between an hour before and an hour after they were ordered for a resident. The DON confirmed the late administrations by multiple nurses in the month of August 2025. The DON stated they will educate current staff members to ensure timely administration of medication.

Based on observations and staff interviews, the facility failed to 1) maintain a sanitary and comfortable environment, as evidenced by persistent odors of urine and unsanitary conditions throughout multiple resident care units and common areas. This deficient practice was observed on six separate dates during the survey; and 2) maintain residents' bathing/shower rooms that were operational and in good repair to meet the basic hygiene needs and preferences of the facility's residents. This was evident for 9 out of 12 resident bathing/shower stalls observed during the survey. The findings include:1. On 08/14/2025 at 7:30 AM, upon entry into the facility, the surveyor detected a strong, pungent odor of urine in the main lobby, which was consistently present throughout the hallways of Unit A, Unit C, and the conference room.On 08/14/2025 at 8:30 AM, the surveyor detected a strong urine odor consistently present throughout the hallways of Unit B.On 08/14/2025 at 10:40 AM, during an interview, the Director of Nursing (DON, Staff #2) acknowledged the surveyor's observations and stated, Yes, we have talked about the odor in the building with housekeeping.On 08/14/2025 at 10:46 AM, the Housekeeping Manager (Staff #14) reported that three housekeepers were assigned, one per unit, from 7:00 AM–2:00 PM daily, and confirmed that no housekeeping staff were present in the facility after 2:00 PM.On 08/15/2025 at 7:30 AM, on Unit C, the surveyor observed:A yellow puddle of fluid approximately 10 inches x 4 inches on the hallway floor with a strong odor of urine.A dark brown moist substance approximately 3 inches x 3 inches on the wall near the shower room.After surveyor intervention, housekeeping staff cleaned the area.On 08/19/2025 at 2:55 PM, the surveyor, accompanied by Staff #23 and Staff #24, observed a strong odor of urine and feces in the hallway of Unit C, traced to the soiled utility room. Upon entering, the surveyor noted large trash cans filled and overflowing with multiple bags containing soiled incontinent products.During an interview, Staff #23 stated, The odor is bad in this hallway. The laundry staff are supposed to take out the trash, but after 9:00 PM there is no housekeeping or laundry staff, and there are no cleaning supplies for us to use if a resident has an accident. There is not enough staff to handle all the trash and cleaning.Staff #24 stated, There is always an odor in this place, and if you call laundry after housekeeping leaves at 2:00 PM, they don't know where the cleaning supplies are or what to do.On 08/25/2025 at 11:00 AM, the surveyor again detected a strong odor of urine throughout the hallways of Units A, B, and C. 2. During observation rounds of the facility bathing/shower rooms on 08/18/2025 at 8:50 AM with Nursing Home Administrator and staff #12 there were a total of 12 resident bathing/shower stalls for resident use within the facility. 9 out of the 12-facility bathing/shower stalls were found unusable to bath residents due to the facility using the stalls as storage for boxes, wheelchairs, bedside tables, oxygen concentrators, resident mattresses, and other medical devices. 2 out of the 9 unusable facility bathing/shower stalls did not have a shower head connected to the shower faucet piping. During an interview, while making observation rounds, on 08/18/2025 at 8:50 am the Nursing Home Administrator (NHA) stated and agreed that there were only 3 out of 12 facility bathing/shower stalls able to be used for resident bathing/shower needs and preferences. The NHA also agreed and stated that 9 out of 12 bathing/shower stalls were unusable as well as that there were no resident room bathrooms with bathing/shower stalls within the facility that could be used to bathe/shower residents.

Based on record review and interviews with resident and staff, it was determined that the facility failed to maintain accurate medical records in accordance with accepted professional standard and practices. This was evident for 11 (Resident #11, #23, #33, #34, #41, #13, #27, #72, #84, #5, and #97) residents out of 68 residents reviewed during the annual survey.The findings include: Bedrails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident's Representative should be provided with the risks and benefits along with a signed consent obtained before the use of bedrails. 1. On [DATE] at 11:18AM, during an interview with Resident #11, the Surveyor observed the resident lying in bed with the head of the bed at about 30 degrees. There were quarter size bed rails raised on both sides at the top of the bed. The resident stated that the bed rails assist them with bed mobility. On [DATE] at 12:25PM, during rounds on the A wing nursing unit, the Surveyor observed Resident #11 lying in bed with the head of the bed at about 30 degrees. The quarter size bed rails were raised on both sides at the top of the bed. On [DATE] at 11:35AM, a review of Resident #11’s electronic medical record revealed a Bed Safety Evaluation dated [DATE] and a Bed Safety Evaluation Follow-up dated [DATE], with quarter size bed rails recommended on both sides of the bed for mobility. The final action for bed rail use was to obtain consent and obtain a physician’s order. Further review failed to reveal resident or resident representative consent nor a physician’s order for bed rail use. 2. On [DATE] at 11:34AM, the Surveyor observed Resident #34 sitting on the right side of their bed with their feet touching the ground. The resident was using the right quarter bed rail to hold themselves upright with the left hand. On [DATE] at 8:30AM, during an interview with Resident #34, the Surveyor observed the resident lying flat in bed with both quarter bed rails raised at the top of the bed. The resident used the bed rail to adjust themselves in bed. On [DATE] at 11:45AM, a review of Resident #34’s electronic medical record revealed a Bed Safety Evaluation dated [DATE] and a Bed Safety Evaluation Follow-up dated [DATE], with quarter size bed rails recommended on both sides of the bed for mobility. The final action for bed rail use was to obtain consent and obtain a physician’s order. Further review failed to reveal resident or resident representative consent nor a physician’s order for bed rail use. During an interview with the Director of Nursing (DON) on [DATE] at 12:20PM, the Surveyor was informed that Resident #11 and Resident #34 use the quarter bed rails for mobility. The facility only uses the quarter bed rails at the top of the bed. Any resident who uses bed rails should have a Bed Safety Evaluation and Bed Safety Evaluation Follow-up (if recommended to use bed rails) completed on admission or whenever initiating the use of bed rails. Resident or resident representative consent and a physician’s order is obtained prior to use. The Surveyor expressed the concern that Resident #11 nor Resident #34 had an order for the use of side rails and resident or resident representative consent in their electronic medical record and requested that documentation. On [DATE] at 2:30PM, the DON and Surveyor confirmed that Resident #11and Resident #34 had signed consent, however failed to have a physician orders for the use of quarter bed rails. The DON conducted a house-wide audit, and new orders for Resident #11 and Resident #34 were received. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used in emergencies in which someone’s breathing or heartbeat has stopped. Do Not Resuscitate (DNR) is an order placed in a person’s medical record by a doctor informs the medical staff that CPR should not be attempted. Do Not Intubate (DNI) is an order placed in a person’s medical record by a doctor informs the medical staff that chest compressions and cardiac drugs may be used, but no breathing tube will be placed. 3. On [DATE] at 11:49AM, the Surveyor reviewed a MOLST form. According to the MOLST form, within Option A, prior to arrest, administer all medications needed to stabilize the patient. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. There is option A-1, allowing intubation and option A-2, Do Not Intubate (DNI). A review of Resident #23’s current MOLST form dated [DATE], indicated that the resident requests No CPR option A-1, which states that comprehensive efforts may include intubation and artificial ventilation. On [DATE] at 10:45AM, a review of Resident #23’s electronic medical record revealed a physician’s order for DNR. Additional review of the resident’s electronic medical record revealed a Social Services Assessment and Documentation form completed on [DATE]. Within Section 5g., Resident Rights/Healthcare Decision Making/Advanced Directives, it is noted that “per resident request the following orders are in place: DNR/DNI. On [DATE] at 12:05PM, during an interview with the Director of Nursing (DON), the Surveyor expressed the concern that Resident #23’s MOLST indicated that the resident was No CPR (DNR) Option A-1 allowing intubation and the Social Services Assessment Documentation indicated the resident was DNR/DNI, not allowing intubation. The DON stated she would review the concern with Social Service Director #3. On [DATE] at 1:30PM, during an interview with the Social Service Director #3, the Surveyor was informed that Resident #23 is No CPR (DNR) Option A-1, allowing intubation. Social Services Director #3 stated that the information in the Social Services Assessment and Documentation form, Section 5g., completed on [DATE], was incorrect and will provide education to the staff member who completed the document. The document was updated to reflect the resident’s current code status. Preadmission Screening and Resident Review (PASRR) is a federal program that screens individuals applying to or reside in Medicaid-certified nursing facilities for serious mental illness (SMI) or intellectual disability (ID). The purpose is to ensure these individuals receive the most appropriate and least restrictive care setting and services. 4. On [DATE] at 9:30AM, during a review of Resident #11’s electronic medical record, the Surveyor discovered that the resident had diagnoses of, but not limited to, schizoaffective disorder, bipolar type, major depressive disorder, and vascular dementia without behavioral, psychotic, or mood disturbance, and anxiety. On [DATE] at 11:23AM, during a review of Resident #11’s PASRR dated [DATE], the Surveyor noted that Section C1: Diagnosis. Does the individual have a major mental disorder? “No” was checked off. On [DATE] at 12:00PM, during an interview with Social Services Director #3, the Surveyor was informed that examples of diagnoses that would indicate major mental disorder would include schizophrenia, bipolar disorder, major depression, and anxiety disorder. The Surveyor expressed the concern that Resident #11’s current PASRR did not reflect his/her current mental health diagnoses. According to the resident’s diagnosis information, in their electronic medical record, the resident was diagnosed with major depressive disorder [DATE], depression [DATE], and schizoaffective disorder, bipolar type [DATE]. Social Service Director #3 stated that at the time the initial PASRR was completed, Resident #11 was not diagnosed with a major mental disorder. The Surveyor and the Social Services Director #3 confirmed the resident’s current diagnosis, and determined that the resident should have had a new PASRR completed to reflect the resident’s current mental health status to ensure he/she receives the appropriate care. Social Services Director #3 stated that she would review Resident #11’s medical record to see if he/she has a updated PASRR. On [DATE] at 1:30PM, Social Services Director #3 informed the Surveyor that she was unable to locate an updated PASRR which included current diagnoses of major depression and schizoaffective disorder, bipolar type. Social Services Director #3 stated that she would complete a new PASRR for Resident #11. On [DATE] at 3:39PM, Social Services Director #3 provided the Surveyor with a updated copy of Resident #11’s PASRR. 5. On [DATE] at 9:05AM, the Director of Nursing (DON) provided the Surveyors with a copy of the facility’s current list of independent smokers. The DON stated that residents on the list were able to smoke independently. Resident #33 was on the current list as an independent smoker. On [DATE] at 1:00PM the DON provided the Surveyors with an updated independent smoking list. The DON stated that residents on the list were able to smoke independently. Resident #33 was on the current list as an independent smoker. During a review of Resident #33’s electronic medical record on [DATE] at 1:45PM, the Surveyor discovered a current Smoking Evaluation completed on [DATE] which indicated the resident needed to be supervised while smoking and a note that states the “patient attempts to keep [his/her] liter on person.” On [DATE] at 3:05PM, the DON provided the Surveyors with an updated independent smoking list. The DON stated that residents on the list were able to smoke independently. Resident #33 was on the current list as an independent smoker. On [DATE] at 10:15AM, a review of Resident #33’s electronic medical record revealed the same Smoking Evaluation completed on [DATE] which indicated the resident needed to be supervised while smoking and a note that states the “patient attempts to keep [his/her] liter on person.” During an interview with the DON on [DATE] at 10:45AM, the Surveyor expressed the concern that Resident #33 had a current Smoking Evaluation completed on [DATE] which indicated the resident needed to be supervised while smoking and that the current smoking list provided on [DATE] at 3:05PM, listed the resident as an independent smoker. The DON stated that the resident only smokes when family comes in and takes him/her outside to smoke. The Surveyor asked, “Does this resident need to be supervised while smoking?” The DON stated she would get back to the Surveyor. On [DATE] at 3:00PM, the DON provided the Surveyors with a copy of the updated smoking list. Resident #33 was listed as a supervised smoking resident who only smokes with family. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident’s functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. 6. On [DATE] at 11:00AM, a review of Resident #41’s electronic medical record revealed that the resident had diagnoses of, but not limited to, contracture of the left hand, muscle weakness, abnormalities of gait and mobility, functional quadriplegia, and dementia. On [DATE] at 11:21AM, during a review of Resident #41’s electronic medical record, the Surveyor discovered an Annual MDS assessment from [DATE]. Section GG identifies the resident’s functional abilities. According to Section GG, Resident #41 has impairment to one side of the upper extremity, no impairment of the bilateral lower extremity, uses a wheel chair, was dependent with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The resident was dependent with roll left and right, sit to lying, lying to sitting on the side of the bed, independent with sit to stand, setup or clean up assistance with chair/bed to chair transfer, and substantial/maximal assistance with toilet transfer. Further review revealed Geriatric Nursing Assistant Point of Care documentation for [DATE] which indicated that the resident was dependent with ADL cares, bathing, personal hygiene, dressing, bed mobility, transfers, locomotion, and required the use of mechanical lift to get out of bed. On [DATE] at 12:20PM, during an interview with the Director of Nursing (DON), the Surveyor expressed the concern that Section GG of the Annual MDS assessment completed on [DATE], indicated Resident #41 was independent with sit to stand, setup or clean up assistance with chair/bed to chair transfer, and substantial/maximal assistance with toilet transfer. The DON stated that Resident #41 was total dependent with all ADL care, bed mobility, and transfers. The resident is transferred out of bed using a Hoyer lift (mechanical lift) and he/she cannot stand on their own. The DON stated she would look into the Annual MDS assessment from [DATE]. 7. On [DATE] at 10:41 AM, Resident #13's medical record was reviewed. During the medical record review, the resident’s eINTERACT Change in Condition Evaluation - V 5.1, dated [DATE], in section 1. General Background Information, in 1. Is the resident/patient in the facility for:, 3. Other is selected and under 1a3a. If other, specify: it states hospice. On [DATE] at 11:03 AM, the facility's records were reviewed. During the facility record review, the matrix did not indicate that Resident #13 was receiving hospice care. On [DATE] at 11:16 AM, the surveyor interviewed the Director of Nursing staff #2. During the interview, the surveyor asked staff #2 if Resident #13 was on hospice. Staff #2 stated that Resident #13 was on hospice. On [DATE] at 2:36 PM, the surveyor interviewed staff #2. During the interview, the surveyor made staff #2 aware that according to the matrix, Resident #13 was not listed as being on hospice. Staff #2 stated that she was not sure why Resident #13 was not listed on the matrix as being on hospice. On [DATE] at 8:06 AM, the surveyor interviewed staff #2. During the interview, staff #2 stated that the resident was not listed on the matrix, because she did not click the refresh button when she entered data on the matrix. 8. On [DATE] at 9:05 AM, the facility's records were reviewed. The facility record review revealed that Resident #27 was listed on the facility’s smoker list. On [DATE] at 9:06 AM, the surveyor interviewed staff #2. During the interview, staff #2 stated that all smokers listed on the facility's smoker list can smoke independently. On [DATE] at 1:31 PM, Resident #27’s medical records were reviewed. The medical record review revealed that Resident #27’s Smoking Evaluation (SNF) - V 4, dated [DATE], in 1. Smoking decision under E. Evaluation states that Supervised smoking is required. On [DATE] at 1:36 PM, Resident #27's medical record was reviewed. During the medical record review, the resident’s care plan states Patient may smoke with supervision per smoking evaluation. On [DATE] at 11:47 AM, the surveyor interviewed staff #2. During the interview, the surveyor made staff #2 aware that Resident #27’s Smoking Evaluation (SNF) - V 4 and care plan do not indicate that Resident #27 can smoke independently. Staff #2 stated that she will update the facility’s smoker list. 9. On [DATE] at 9:05 AM, the facility's records were reviewed. The facility record review revealed that Resident #72 was listed on the facility’s smoker list. On [DATE] at 9:06 AM, the surveyor interviewed staff #2. During the interview, staff #2 stated that all smokers listed on the facility's smoker list can smoke independently. On [DATE] at 1:45 PM, Resident #72’s medical records were reviewed. The medical record review revealed that Resident #72 did not have a Smoking Evaluation (SNF) - V 4 documented. On [DATE] at 1:52 PM, Resident #72's medical record was reviewed. The medical record review revealed that Resident #72 was not care planned for smoking. On [DATE] at 11:48 AM, the surveyor interviewed staff #2. During the interview, the surveyor made staff #2 aware that Resident #72 does not have a Smoking Evaluation (SNF) - V 4 documented, and Resident #72 was not care planned for smoking. On [DATE] at 3:06 PM, the surveyor interviewed staff #2. During the interview, staff #2 stated that Resident #72 no longer smokes. Staff #2 also stated that she will update the facility’s smoker list. 9. On [DATE] at 9:05 AM, the facility's records were reviewed. The facility record review revealed that Resident #84 was listed on the facility’s smoker list. On [DATE] at 9:06 AM, the surveyor interviewed staff #2. During the interview, staff #2 stated that all smokers listed on the facility's smoker list can smoke independently. On [DATE] at 1:48 PM, Resident #84’s medical records were reviewed. The medical record review revealed that Resident #84’s Smoking Evaluation (SNF) - V 4, dated [DATE], in 1. Smoking decision under E. Evaluation states that Supervised smoking is required. Also, “1a. Reason/Additional Comments” of E. Evaluation states “to be supervised at all time[s]”. On [DATE] at 1:51 PM, Resident #84's medical record was reviewed. The medical record review revealed that the resident’s care plan stated Patient may not smoke cigarette per smoking evaluation. On [DATE] at 3:16 PM, the surveyor interviewed staff #2. During the interview, the surveyor made staff #2 aware that Resident #84’s Smoking Evaluation (SNF) - V 4 does not indicate that Resident #84 was an independent smoker, and that Resident #84’s care plan stated Patient may not smoke cigarette per smoking evaluation. Staff #2 stated that she will review Resident #84’s care plan. On [DATE] at 9:41 AM, the surveyor interviewed staff #2. During the interview, staff #2 stated that she will update Resident #84’s Smoking Evaluation(SNF) - V 4 and care plan to reflect Resident #84 as an independent smoker. 10. Review of Resident #5's medical record on [DATE] at 08:00 AM revealed a Medication Administration Record (MAR) for the month of [DATE] with a physician order dated [DATE]; Is resident free from side effects of psychotherapeutic medications? (If no, document side effects in PN) every shift for Monitoring. Further review of the MAR revealed that staff documented “No” on [DATE] on evening and night shift. On 08/02, 08/03, 08/04, 08/05, 08/06, 08/07, 08/08, 08/09, 08/10, 08/11, 08/12, 08/13, 08/14, 08/15, 08/16, [DATE] on day, evening and night shift, there were no progress notes (PN) documenting the side effects that were found. During an interview on [DATE] at 10:00 AM the Director of Nursing stated “that the letters (PN) noted on Resident #5's order dated [DATE]; Is resident free from side effects of psychotherapeutic medications? (If no, document side effects in PN) every shift for Monitoring, means to document side effects in Resident #5's medical record under Progress Notes (PN), there were no progress notes completed for staff members who documented no, staff should have completed a progress note and or the staff are documenting incorrectly”. 11. During observation rounds and interview on [DATE] at approximately 8:10 AM, Resident #97 was found in his/her room holding a green and white in color pack of cigarettes as well as a blue lighter. Resident #97 stated that, “Yes I smoke, and these items belong to me”. On [DATE] at 9:05 AM a list of facility smokers was provided to the survey team by the facility and revealed that Resident #97 was not listed as a smoker. During an interview on [DATE] at 1:00 PM the Director of Nursing staff #2 (DON) brought an updated list of residents that smoke and stated, “Resident #97 should have been on the list of facility smokers because Resident #97 smokes”. Review of updated list of facility smokers at [DATE] at 1:00 PM revealed that resident #97 was added to the list.

Based on observations and staff interviews it was determined the facility failed to store food in accordance with professional standards for food safety during the annual survey.The findings include: An initial tour of the facility kitchen was completed on 08/14/2025 at 08:03 AM with staff (#6) and the following items were found to be missing an expiration date on the product: 1) One 7 lb. can of Banana Pudding 2) One 6.56 lb. can of Ultra-Premium Marinara Sauce 3) Several spice containers of spices 4) Five 5oz packages of Reduced Calorie Vanilla Pudding and Pie Filling mix During the tour interview on 08/14/2025 at 08:03 AM with staff #6 he/she confirmed and stated that the above items did not have an expiration date on them, and staff were supposed to label all food items with an expiration date. During interview on 08/14/2025 at 2:25 PM staff #7 stated that all food items are to be labeled by staff with an expiration date upon being received.

Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment for the residents. This was evident for 4 resident rooms out of 21 resident rooms observed on the A wing nursing unit and 3 resident rooms out of 11 resident rooms reviewed on the B wing nursing unit during the survey. The findings include: 1.) On 8/14/2025, during a tour of the A wing nursing unit between 8:30AM and 10:20AM, the Surveyor observed the following environmental concerns: 1a. In room [ROOM NUMBER]A, the privacy curtain, which separated the 2 bed spaces, was soiled with scattered white smears and reddish-brown spots. 1b. In room [ROOM NUMBER]A, the privacy curtain, which separated the 2 bed spaces, was soiled with scattered white smears. On 8/15/2025, during a tour of the A wing unit between 8:15AM and 9:40AM, the Surveyor observed the following environmental concerns: 1c. In room [ROOM NUMBER]A, the baseboard under the air conditioning unit was damaged, the phone jack outlet being used on the back wall between the residents' head of the bed was loosely sticking out of the wall and held in place with a black duct tape like product surrounding all four sides. 1d. In room [ROOM NUMBER]A and 8A, the over-the-toilet commode in the shared bathroom had rust build-up and damage on the front of the frame and the legs. On 8/18/2025 between 8:20AM and 8:45AM, the Surveyors conducted an environmental tour of the A wing, B wing, and C wing nursing units and an interview with the Nursing Home Administrator (NHA) and Maintenance Director #12. During a tour of the A wing, this Surveyor made the NHA and Maintenance Director #12 aware of the concerns regarding the observations of the soiled privacy curtains in rooms 08A and 19A on 8/14/2025 and rust build-up on the over-the-toilet commode in the shared bathroom in 6A and 8A on 8/15/2025. The NHA and Maintenance Director #12 stated that they would make sure the concerns were addressed. On 8/20/2025 at 12:35PM, the Surveyor and the Director of Nursing (DON) confirmed the environmental concerns in room [ROOM NUMBER]A. The DON stated she would have Maintenance Director #12 take care of the issue. 2. During observation rounds on 08/14/2025 the following concerns were found: 2a. At 8:35 AM in room [ROOM NUMBER]B-1: Behind the resident's bed was peeling paint with several gouges of plaster missing from the wall. 2b. At 8:40 AM in room [ROOM NUMBER]-B: The cove base was missing on wall behind the door entering the room. 2c. At 9:10 AM in room [ROOM NUMBER]-B: The calking around the resident bathroom sink was cracked, brownish gray in color and the sink was disconnecting from the wall. The air vent grate on the wall of the bathroom was dented, brown and black in color, with a musty smell. The bathroom cove base was peeling from the walls and there was dry wall missing on wall to the right after entering the bathroom door. The toilet seat lid was found broken and not attached to the toilet. During an interview on 08/14/2025 at 9:08 AM resident #79 stated, The bathroom does not look good and the lid to the toilet is broken. During an interview on 08/14/2025 at approximately 10:00 AM the Director of Nursing (DON) was made aware of the concerns found on observation rounds in residents' rooms. The DON stated, I will let Maintenance know. During observation rounds and interview on 08/18/2025 at 8:50 AM with Nursing Home Administrator staff #1 and staff #12, all concerns were visual shown and reviewed regarding resident rooms. During these rounds staff #12 stated, these items will be fixed.

Based on review of facility reported incidents (FRIs) and interview with staff, it was determined that the facility failed to report allegations of abuse within 2 hours to the Office of Health Care Quality (OHCQ). This was evident for 3 (#356914, #356923, and #356927) FRI's out of 15 FRI's reviewed during the annual and complaint survey.The findings include: 1. On 08/25/25 at 01:46 PM, the Facility Reported Incident #356917 was reviewed. The Facility Reported Incidents revealed that on 7/31/24 at 1:00 PM, the facility was made aware by the resident's representative that during the 11:00 PM – 7:00 AM shift on 7/29/24, the resident's representative alleged that he/she heard two staff members verbally abusing Resident #112. The facility interviewed the resident and the resident stated that he/she heard Geriatric Nursing Assistant staff #20 and Licensed Practical Nurse staff #21 speaking negatively about him/her and his/her representative. The Facility Reported Incidents also revealed that the facility submitted the initial Facility Reported Incident to the Office of Health Care Quality (OHCQ) on 8/1/24 at 11:57 AM. On 08/25/25 at 3:03 PM, the surveyor interviewed the Nursing Home Administrator staff #1. During the interview, the surveyor made staff #1 aware that according to the facility's initial Facility Reported Incident, the facility became aware of the verbal abuse allegations on 7/31/24 at 1:00 PM, and they submitted the initial Facility Reported Incident to OHCQ on 8/1/24 at 11:57 AM. Staff #1 stated that he believes that he made an error on the submission date and time listed on the initial Facility Reported Incident and will follow-up with the surveyor after he checks his files. On 08/25/25 at 4:03 PM, the surveyor interviewed staff #1. During the interview, staff #1stated that he tried to submit the initial Facility Reported Incident to OHCQ on 7/31/24 while he was home; however, when he arrived at the facility, he realized that the initial Facility Reported Incident did not submit to OHCQ. Staff #1 agreed with the surveyor that the initial Facility Reported Incident, regarding abuse allegations, was not submitted to OHCQ within the required two-hour window. 2. On 8/21/2025 at 3:00PM, during a review of the investigative file for facility reported incident #356923, the Surveyor discovered that Resident #34 reported an allegation of abuse on 9/30/2024 at 5AM to a registered nurse. The Nursing Home Administrator (NHA) was informed about the incident at 5:30AM. Further review of the investigative file revealed that the facility initiated an investigation and the Nursing Home Administrator (NHA) submitted the initial report to OHCQ on 9/30/2024 at 11AM, not within the 2-hour time frame for an allegation of abuse. On 8/25/2025 at 4:00PM, the Surveyor and the NHA confirmed that the facility failed to report FRI #356923 within 2 hours, as required for an allegation of abuse. 3. On 08/21/25 at 3:24 PM during Record Review of FRI #356927 regarding Resident #120 the initial report revealed that staff became aware of an alleged physical incident on 12/22/24 at 3:30 AM and reported it to Nursing Home Administrator Staff #1 (NHA) on 12/22/24 at 3:45 AM. However, the FRI was submitted to OHCQ at 10:48 AM. This reflects over 7hrs later, not within the regulation timeframe of 2 hours. On 08/25/25 at 10:5 AM during an interview with Nursing Home Administrator Staff #1 (NHA) we discussed the time delay. NHA Staff #1 states that the reporting was delayed because I did not have access to a computer at the time of being made aware. When asked what the facility normal reporting procedures are when the NHA is unable to submit a timely report, NHA Staff #1 stated the DON or other designated staff member could submit the report to OHCQ as well. NHA Staff #1 further stated, this did not occur.

Based on observations and interviews of facility staff it was determined the facility failed to ensure effective pest control as flying gnats and flies were observed throughout the building. This was found to be evident during the survey.The findings include: On 8/14/2025, during a tour of A wing nursing unit between 8:30AM and 10:20AM, the Surveyor observed the following concerns:1.) In room [ROOM NUMBER]A-1 and 2, multiple gnats were noted flying around the room.2.) In room [ROOM NUMBER]A-2, multiple gnats observed on used tissues sitting on Resident #1's bedside table.3.) In room [ROOM NUMBER]A-1 and 2, gnats and flies observed flying around the room. Resident #2 stated that the gnats and flies have been an issue within the facility.On 8/14/2025 at 10:25AM, while walking down C wing hallway towards the conference room, the Surveyor observed gnats flying.On 8/15/2025, during a tour of the A wing nursing unit at 8:15AM through 9:40AM, the Surveyor observed the following concerns:1.) In room [ROOM NUMBER]A-1 and 2, multiple gnats observed flying around the resident's room.2.) In room [ROOM NUMBER]A-1, flies were observed crawling on Resident #41.3.) In room [ROOM NUMBER]A-2, gnats observed on Resident #34's side of the room4.) In room [ROOM NUMBER]A-1 and 2, flies observed flying around room and gnats in bathroom On 8/18/2025 between 8:20AM and 8:45AM, the Surveyors conducted an environmental tour of the A wing, B wing, and C wing nursing units and an interview with the Nursing Home Administrator (NHA) and Maintenance Director #12. During the walk through of B wing and room [ROOM NUMBER]B, Resident #22 appeared upset and informed the Surveyors, NHA, and Maintenance Director #12 that the gnats are an issue in his/her room and they are constantly flying around while eating meals. During a tour of the A wing, this Surveyor made the NHA and Maintenance Director #12 aware of the concerns regarding the observations of gnats and flies within the facility and in rooms 08A, 16A, and 18A on 8/14/2025 and rooms 02A, 3A, 04, and 06A on 8/15/2025.On 8/18/2025 at 9:00AM, an interview with the NHA, the Surveyor expressed the concern that the facility failed to maintain effective pest control. The Surveyor was informed that the facility utilizes [Pest Control Company] and that a representative visits a couple times a month and as needed.On 8/19/2024 at 3:15PM, a representative from [Pest Control Company] and the NHA confirmed visits to the facility 2 to 3 times a month. The representative reviews the pest control log and treats the area's identified in the log since the last time he visited. The [Pest Control Company] representative attributed the residents' own food items to the presence of flies and gnats in some rooms, however, was unable to explain the presence of flies and gnats in rooms that did not have food items. The NHA and the [Pest Control Company] representative stated that they would develop and implement interventions to control the presence of flies and gnats within the facility.

Based on observation, record review, and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for residents. This was evident 3 out of 13 residents (Resident #13, #41, #97) investigated for smoking during the survey.The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. 1. On 08/20/25 at 10:41 AM, Resident #13's medical record was reviewed. During the medical record review, the resident's eINTERACT Change in Condition Evaluation - V 5.1, dated 6/27/25, in section 1. General Background Information, under 1. Is the resident/patient in the facility for:, 3. Other is selected and under 1a3a. If other, specify: it states hospice. On 08/20/25 at 10:53 AM, Resident #13's medical record was reviewed. During the medical record review, the resident's care plan stated Hospice start date 6/25/23 Hospice care due to end stage diagnosis of _______. In the resident's care plan, the surveyor could not locate interventions for hospice care. The record review revealed that the resident was admitted to the facility on [DATE]. On 08/20/25 at 11:16 AM, the surveyor interviewed the Director of Nursing staff #2. During the interview, the surveyor asked staff #2 if Resident #13 was receiving hospice care. Staff #2 stated that Resident #13 was on hospice. On 08/20/25 at 2:36 PM, the surveyor interviewed staff #2. During the interview, the surveyor made staff #2 aware that Resident #13's care plan for hospice did not list any interventions. Staff #2 stated she was not certain why the care plan did not list any interventions for hospice care. 2. On 8/15/2025 at 9:18AM, the Surveyor observed Resident #41 lying in bed awake with the head of the bed raised to 30 degrees. The Surveyor introduced themselves to the resident. The resident moved his/her head back and forth and finally stared towards the wall. The resident did not acknowledge the Surveyor's presence. On 8/18/2025 at 10:30AM, a review of Resident #41's electronic medical record revealed that the resident had a diagnosis of, but not limited to, dysphagia, dementia, and aphasia. Further review revealed an annual MDS assessment dated [DATE]. Section B: indicated the resident had adequate hearing and vision, unclear speech and rarely makes self understood; Section C indicated the resident had severe cognitive impairment; and Section I indicated the resident had a diagnosis of aphasia. On 8/18/2025 at 11:10AM, an additional review of Resident #41's electronic medical record failed to reveal a care plan for impaired communication. On 8/18/2025 at 1:01PM, during an interview conducted with Licensed Practical Nurse (LPN) #26, the Surveyor was informed that the Resident #41 would express themselves verbally to certain people. The resident could understand and follow some commands. The resident used hand gestures and shakes his/her head yes or no to communicate his/her needs with staff. LPN #26 had no concerns with the resident communicating their needs indicating not all staff are familiar with the resident or know that he/she can at times communicate verbally because he/she does not express himself to everyone. On 8/19/2025 at 12:00PM, during an interview with the Director of Nursing (DON), the Surveyor was informed that the DON was unaware that Resident #41 was verbal. The Surveyor expressed the concern that the resident failed to have a care plan for impaired communication and interventions on ways to communicate with the resident. On 8/19/2025 at 1:00PM, the DON provided the Surveyor with a copy of a care plan for impaired communication developed on 8/19/2025 by A wing Unit Manager (UM) #5. 3. Review of Resident #97's medical record on 08/14/2025 at 12:00 PM revealed a Care Plan dated 07/31/2025 with a focus area that patient may smoke independently per smoking evaluation but contained no interventions. During an interview on 08/14/2025 at approximately 12:05 PM the Director of Nursing (DON) agreed there were no interventions listed and stated that the Care Plan for Resident #97 should have interventions listed on it. On 08/14/2025 at 1:00 PM after surveyor intervention, the Director of Nursing gave surveyor an updated care plan for Resident #97 with interventions regarding smoking.

Based on surveyor observations, facility record reviews, and staff interviews, it was determined that the facility failed to: 1) maintain proper temperature controls for stored drugs and biologicals; 2) ensure the removal of expired emergency medication from the medication storage room; 3) ensure that residents' medication is stored in the medication carts; and 4) ensure the removal of expired medication from the medication cart. This was evident for 2 of 2 medication storage rooms and 1 of 4 medication carts reviewed during an annual recertification survey.The findings include:1. On [DATE] at 10:25 AM, a medication storage observation was conducted. During the medication storage observation, the surveyor observed a buildup of ice in Unit C's medication storage room freezer.On [DATE] at 10:26 AM, the facility's records were reviewed. The facility record review revealed that the facility's Temperature Log for Refrigerator and Freezer did not have documentation of the temperature of Unit C's medication storage room freezer.On [DATE] at 10:30 AM, the surveyor interviewed the Unit C Manager staff #9. During the interview, the surveyor made staff #9 aware of the buildup of ice in Unit C's medication storage room freezer, and the lack of documentation of Unit C's medication storage room freezer temperature on the facility's Temperature Log for Refrigerator and Freezer. Staff #9 agreed that there were thick layers of ice in Unit C's medication storage room freezer. Staff #9 stated that she was not aware that she needed to document the temperature of Unit C's medication storage room freezer.2. On [DATE] at 10:28 AM, a medication storage observation was conducted. During the medication storage observation, the surveyor observed an expired emergency medication kit (Genesis ANA Kit) with an expiration date of February 2025 in Unit C's medication storage room. The emergency medication kit (Genesis ANA Kit) contained: 2 expired Epinephrine (Adrenaline) 1:1,000 auto-jectors with a [DATE] expiration date; 2 Haldol IM 5 mg/5ml (Haloperidol) with an expiration date of [DATE]; 4 Mephyton 5 mg tablets (Phytonadione) with an expiration date of [DATE]; and 2 Phenergan Injection 50mg/ml (Promethazine) with an expiration date of February 2025.On [DATE] at 10:30 AM, the surveyor interviewed staff #9. During the interview, the surveyor made staff #9 aware of the expired emergency medication kit (Genesis ANA Kit) in Unit C's medication storage room. Staff #9 agreed that the emergency medication kit (Genesis ANA Kit) was expired.On [DATE] at 1:09 PM, the surveyor interviewed the Director of Nursing staff #2. During the interview, the surveyor asked staff #2 explain the process for keeping the emergency medication kit (Genesis ANA Kit) up-to-date. Staff #2 stated PharMerica, the pharmacy the facility uses, comes to the facility to update the emergency medication kit (Genesis ANA Kit) by exchanging the kits for newer ones. Staff #2 also stated that she is not certain why emergency medication kit (Genesis ANA Kit) ) in Unit C's medication storage room was not exchanged for a newer kit.3. On [DATE] at 10:49 AM, a medication storage observation was conducted. During the medication storage observation, the surveyor observed 2 blister packs of Isosorbide Mononitrate 120 mg Extended Release for Resident #69 and Albuterol Sulfate Inhalation Solution, 0.083% 2.5 mg/3 ml for Resident #99 stored in a drawer in Unit B's medication storage room.On [DATE] at 10:50 AM, the surveyor interviewed the Unit B Manager staff #10. During the interview, the surveyor made staff #10 aware of the 2 blister packs of Isosorbide Mononitrate 120 mg Extended Release for Resident #69, and the Albuterol Sulfate Inhalation Solution, 0.083% 2.5 mg/3 ml for Resident #99 stored in a drawer in Unit B's medication storage room. Staff #10 mentioned that she was not certain why residents' medication was stored in a drawer in the medication storage room. Staff #10 also mentioned that Resident #69 was discharged .On [DATE] at 1:11 PM, the surveyor interviewed staff #2. During the interview, the surveyor asked staff #2 why Resident #69's and Resident #99's medication was stored in a drawer in Unit B's medication storage room. Staff #2 stated that Resident #69 should have received the Isosorbide Mononitrate 120 mg Extended Release blister packs when he/she was discharged since he/she was still on the medication at the time of discharge. Staff #2 also stated that she is not certain why Resident #99's Albuterol Sulfate Inhalation Solution, 0.083% 2.5 mg/3 ml was stored in a drawer in Unit B's medication storage room and not the medication cart, and will ensure that staff #10 places Resident #99's medication in the medication cart.4. On [DATE] at 11:13 AM, a medication cart observation was conducted. During the medication cart observation, the surveyor observed expired Olopatadine Hydrochloride 0.1% eye drops in Unit B's, middle medication cart for Resident #17.On [DATE] at 10:50 AM, the surveyor interviewed staff #10 and Registered Nurse staff #11. During the interview, the surveyor made staff #10 and staff #11 aware of the expired Olopatadine Hydrochloride 0.1% eye drops in Unit B's, middle medication cart for Resident #17. Staff #10 and #11 stated that they would remove Resident #17's expired Olopatadine Hydrochloride 0.1% eye drops from Unit B's, middle medication cart.On [DATE] at 1:13 PM, the surveyor interviewed staff #2. During the interview, the surveyor asked staff #2 why there was expired Olopatadine Hydrochloride 0.1% eye drops for Resident #17 in Unit B's, middle medication cart. Staff #2 stated that she was not certain why there was expired Olopatadine Hydrochloride 0.1% eye drops for Resident #17 in Unit B's, middle medication cart, because Unit B's medication carts were recently checked for expired medication.

Based on record review and interview with staff, it was determined that the facility failed to ensure a resident who requires dental services on a routine or emergent basis receives necessary or recommended dental services in a timely manner. This was evident for 1(Resident #41) reviewed for dental services.The findings include: On 8/18/2025 at 11:10AM, during a review of Resident #41's electronic medical record, the Surveyor discovered the resident's last dental examination was 9/26/2024. Further review revealed a dental note dated 9/26/2024 which stated Not a candidate for surgical extractions or xrays in the facility and remaining teeth have poor prognosis due to periodontal disease, caries, and retained roots. Action required by nursing home staff: Monitor teeth for signs/symptoms of problems; Patient would benefit [from] referral for panoramic xray and extraction with nitrous/IV sedation. Patient at risk for dental infection. Provider continue peridex swabs 2x a day for periodontal disease.On 8/18/2025 at 12:55PM an interview was conducted with A wing Unit Manager (UM) #5. The Surveyor was informed that nursing staff should put orders from consultations into the resident's medical record for the physician to review and sign. Recommendations for further consultation should be reviewed by nursing and appointments should be made accordingly. The Surveyor expressed the concern that Resident #41's last dental visit was 9/26/2024 and reviewed the [Dental Group] note. According to the exam, the resident had poor, general breakdown, heavy soft plaque/food debris buildup, heavy hard calculus deposits, severe [NAME].inflam./swollen bleeding gums, poor periodontal condition, and high risk for caries. The resident's remaining teeth had a poor prognosis due to periodontal disease, caries, and retained roots. Resident #41, at that time, was noted to be non-verbal, have difficulty swallowing, and at risk for dental infection. The Surveyor requested documentation that the resident had a follow up appointment for the dental services required from the last dental exam on 9/26/2024. UM #5 informed the Surveyor that the [Dental Group] will no longer see the resident and has removed the resident from their services. UM#5 and the Surveyor confirmed the resident had not been seen by another dental service provider since 9/26/2024. The Surveyor expressed the concern that Resident #41 was removed from the facility's [Dental group] service and confirmed with UM #5 that the facility made no attempt to schedule an appointment with an outside dental service to meet the dental concerns for the resident. On 8/19/2025 at 12:00PM, the Director of Nursing (DON) provided the Surveyor with a copy of an email from the [Dental Group] which noted that the resident was not a good candidate for onsite treatment due to: patient treatment limited due to patient behavior and tolerance, patient would benefit for referral for panoramic xray and extractions with nitrous/IV sedation, [Dental Group] is unable to provide this form of sedation, and provider placed patient on do not treat status. The Surveyor reviewed the email with the DON and asked if [Dental Group] could no longer provide dental services to Resident #41, why didn't the facility retain an outside dental service for the resident after the examination on 9/26/2024? The DON was unable to provide the Surveyor with an answer. The DON informed the Surveyor that Resident #41 had a dental appointment on 11/7/2025 with an outside dental service.

Based on observation and interview with staff, it was determined that the facility failed to ensure face masks were included Personal Protective Equipment (PPE) inside the PPE carts outside residents' rooms. This was evident for 3 PPE carts on the C wing and 4 PPE carts on the A wing. The findings include: Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. PPE includes, but not limited to, gloves, masks, safety goggles, and gowns. On 8/14/2025 at 8:30AM, during a tour of the C wing nursing unit, the Surveyor observed 3 PPE carts along one side of the hallway. Each cart failed to have face masks inside. On 8/14/2025 at 8:33AM, during a tour of the A wing nursing unit, the Surveyor observed 4 PPE carts along one side of the hallway. Each cart failed to have face masks inside. On 8/14/2025 at 10:19AM, the Surveyor conducted an interview with the Infection Preventionist (IP) #25. The Surveyor was informed that the expectation was for all PPE carts to have gowns, gloves, face shields, and face masks. The Surveyor expressed the concern that 3 PPE carts on the C wing nursing unit and 4 PPE carts on the A wing nursing unit failed to have face masks inside and readily accessible in the resident care area. On 8/14/2025 at 11:30AM, the DON informed the Surveyor that the carts were stocked with masks.

Based on observations and interviews with staff and residents, the facility failed to ensure residents have an enclosed closet space protected from casual access from others by having a closet door. This was found to be evident for 2 out of 21 resident rooms observed during the annual survey.The findings include: On 8/15/2025 at 8:25AM, during a tour of the A wing nursing unit, the Surveyor observed that Resident #41 and Resident #57 did not have closet doors, and their personal belongings were visible. On 8/15/2025 at 8:30AM, an interview conducted with Resident #57 revealed that the closet door had been taken off the hinges months ago because the door was loose and posed a safety issue. The resident was informed that the door would be replaced, and the resident would get a curtain to cover their exposed belongings in the meantime. The resident stated that it never happened and felt uncomfortable with his/her personal belongings exposed to whoever entered the room. On 8/18/2025 at 8:20AM, the Surveyors conducted an environmental tour of the A wing, B wing, and C wing nursing units and an interview with the Nursing Home Administrator (NHA) and Maintenance Director #12. During a tour of the A wing, this Surveyor called attention to Resident #57's room and confirmed the missing door on the resident's closet. This Surveyor also called attention to Resident #41's room and confirmed the missing door on the resident's closet. During an interview, Maintenance Director #12 informed the Surveyor that the closet doors for multiple residents had to be taken down because they were falling off the hinges and posed a safety issue for the residents. He stated that replacing the doors has been a challenge because the company no longer makes that model to properly fit. During an interview, the NHA stated that they have discussed providing the resident's with curtains to cover their belongings in their closet space. The Surveyor expressed the concern that for months, the residents did not have an enclosed closet space to protect their personal belongings from view and casual access to others. On 8/18/2025 at 10:13AM, during an interview with the NHA, the Surveyor was informed that the facility was in the process of ordering new cabinets to replace the damaged ones in the residents' rooms. As of 7/9/2025, the facility received one cabinet. The NHA stated that the facility decided that this will be a gradual process and not happen all at once. The NHA was unable to determine when the residents with missing closet doors would have them replaced with new cabinets.

Based on staff interviews, resident interviews, observations, and facility record reviews, it was determined that the facility failed to provide residents with adequate supervision as evidenced by residents having cigarettes and a lighter stored in their room. This was evident for 2 (Resident #24 and #97) out of 13 residents reviewed for smoking during an annual recertification survey.The findings include: 1. On 08/14/25 at 10:46 AM, the surveyor interviewed the Director of Nursing staff #2. During the interview, staff #2 indicated that residents who are smokers must have their cigarettes and lighters stored in a locked box that is secured at the Receptionist staff #8's desk. Staff #2 also stated that when a resident wants to smoke, they can retrieve their cigarettes (maximum of 2 at a time) and lighter from staff #8, and once the resident is finished smoking the resident must return the lighter to staff #8. On 08/14/25 at 2:16 PM, the surveyor interviewed staff #8. During the interview, the surveyor asked staff #8 if there were cigarettes and a lighter stored at the receptionist area for Resident #24. Staff #8 stated that Resident #24 does not have cigarettes and a lighter stored at the receptionist area. On 08/14/25 at 2:47 PM, the surveyor interviewed Resident #24. During the interview, the surveyor asked Resident #24 if he/she smoked today, and if he/she has cigarettes and a lighter in his/her possession. Resident #24 indicated that he/she smoked today and has his/her cigarettes and lighter in his/her possession. The surveyor also asked Resident #24 if he/she would show the surveyor the cigarettes and lighter. Resident #24 indicated that he/she would show the surveyor the cigarettes and lighter. On 08/14/25 at 2:48 PM, the surveyor observed Resident #24 take his/her cigarettes from his/her dresser located on the right side of the bed. The surveyor observed a green and white pack of cigarettes, labeled Cheyenne, and a gray cigarette lighter. On 08/14/25 at 3:45 PM, the surveyor interviewed staff #2. During the interview, the surveyor made staff #2 aware that Resident #24 has cigarettes and a lighter in his/her room. Staff #2 stated that she would have Unit C Manager staff #9 remove the cigarettes and the lighter from Resident #24's room. On 08/19/2025 at 8:47 AM, the facility's records were reviewed. The facility record review revealed that the facility's OPS137 Smoking policy, under 2.6.1 in 2. For Centers that allow smoking: states that if the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment. Also, the facility's OPS137 Smoking policy, under 2.6.2 in 2. For Centers that allow smoking: states that patients will not be allowed to maintain their own lighter, lighter fluid, or matches. On 08/19/25 at 9:31 AM, the surveyor interviewed the Nursing Home Administrator staff #1 and staff #2. During the interview, staff #1 and staff #2 indicated that although the smoking policy says that if the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment, the facility stores residents' cigarettes and lighters in a secured box located in the receptionist area. 2. During observation rounds and interview on 08/14/2025 at approximately 8:10 AM, Resident #97 was found in his/her room holding a green and white in color pack of cigarettes as well as a blue lighter. Resident #97 stated that, Yes I smoke, and these items belong to me. During an interview on 8/14/2025 at approximately 10:30 AM, the Director of Nursing staff #2 (DON) was made aware that Resident #97 had cigarettes and a lighter in their possession. The (DON) stated that, Resident #97 should not have those items in [his/her] room and staff would go and remove them right away and that any resident that smokes should not have any cigarettes or lighters in their room at any time. During an interview on 8/14/2025 at approximately 12:35 PM staff member #5 stated, I have removed smoking items from [Resident #97] and placed them at the front desk. During an interview on 8/19/2025 at 9:26 AM with the Nursing Home Administrator and Director of Nursing both stated, that any residents that smoke should not have cigarettes, lighters or any smoking items in their rooms and all smoking items should be kept at the front desk even though the facility smoking policy states; if the patient is cognitively and physical able to secure all smoking materials, the Center may allow him/her to maintain his/her tobacco or electronic cigarette products in a locked compartment.

Based on record review and interview with staff, it was determined that the facility failed to 1.) provide written notification of transfer to the resident representative and provide written notification of the facilities bed hold policy upon transfer to the hospital (Resident #41); 2.) ensure the local ombudsman was notified of a facility-initiated transfer to the hospital (Resident #37and #41); and 3.) ensure a resident received accurate written information regarding the bed-hold policy (Resident #109). This was evident for 3 out of 6 residents reviewed for hospitalization during the survey.The findings include: Bed Hold is holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1. On 8/15/2025 at 2:08PM, a review of Resident #41's electronic medical record, the Surveyor discovered that the resident was transferred to the hospital on 4/19/2025, 5/15/2025, and 6/9/2025. Further review failed to reveal documentation to verify Resident #41's resident representative had been notified in writing of the transfer and the facilities bed hold policy for the transfers to the hospital on 4/19/2025, 5/15/2025, and 6/9/2025. During an interview conducted with Business Office Manager #13 on 8/18/2025 at 12:23PM, the Surveyor was informed that when a resident is transferred to the hospital, a Bed Hold Policy & Authorization form and a letter for Notice of Hospital Transfer is completed. Both documents are sent to the resident representative via mail, unless they are present at the facility at the time of transfer. A copy of the documents should be maintained in the resident's medical record. On 8/19/2025 at 1:00PM, Business Office Manager #13 was able to provide a copy of the Bed Hold Notice of Policy & Authorization and letter of Notice of Hospital Transfer for Resident #41's transfer to the hospital on 4/19/2025. The Business Office Manager #13 failed to provide bed hold documentation (Bed Hold Notice of Policy & Authorization) and transfer notification (letter of Notice of Hospital Transfer) for the hospital transfers on 5/15/2025 and 6/9/2025. 2. On 8/18/2025 at 12:20PM, a review of Resident #37's medical record revealed that the resident was transferred to the hospital on 8/7/2025 and 8/9/2025. An interview with Business Office Manager #13 on 8/18/2025 at 12:23PM revealed that once the Bed Hold Notice of Policy & Authorization and letter of Notice of Hospital Transfer are completed, a copy is placed in the resident's medical record, a copy is mailed to the resident representative (if they haven't received it in person), and a copy is mailed to the Ombudsman's office. Business Office Manager #13 makes a copy of the envelope with paperwork that she sends to the Ombudsman and keeps a copy of the envelope in the resident's medical record. Business Office Manager #13 was able to provide the Surveyor with a copy of the Bed Hold Notice of Policy and Authorization and the letter of Notice of Hospital Transfer on 8/7/2025 and 8/9/2025. She was able to provide a copy of the envelope mailed for notification to the Ombudsman's office for the hospital transfer on 8/7/2025 but failed to provide a copy of the envelope mailed to the Ombudsman's office for hospital transfer on 8/9/2025. During an interview with Business Office Manager #13 on 8/20/2025 at 1:15PM, the Surveyor expressed the concerns that the Ombudsman was not notified of Resident #37's transfer to the hospital on 8/9/2025 and Resident #41's transfer to the hospital on 5/15/2025 and 6/9/2025. Business Office Manager #13 and the Surveyor confirmed that she could not provide documentation to verify the Ombudsman was notified of Resident #37's transfer to hospital on 8/9/2025 and Resident #41's transfer to the hospital 5/15/2025 and 6/9/2025. 3. On 5/19/25, Resident #109 was provided with a copy of the facility's bed-hold policy upon transfer to the hospital. Review of the policy showed that the information stated, Medicaid will pay to hold the bed for 15 days, which is not consistent with the state-approved bed-hold duration of no Medicaid bed-hold coverage. During an interview on 8/18/25 at 12:30pm, Staff #13 (Business office Manager) confirmed that this version of the bed-hold policy was the one currently being distributed to residents and acknowledged the information was not correct. Inaccurate information provided to residents regarding bed-hold rights has the potential to mislead residents/representatives about their rights to return to the facility following hospitalization.

Based on observation, staff interview, and record review, the facility failed to ensure that residents were provided care in a manner that protected and promoted dignity for 2 of 3 residents reviewed for dignity (Residents #40 and #93).Findings include: 1. On 8/21/25 at approximately 11:10 AM, during a tour of the shower/tub room, Resident #40 was observed in a shower stall without the privacy curtain being pulled. The shower/tub room contained three shower stalls, a bathtub, and a toilet. At the time of the observation, staff were present rendering morning care; however, the privacy curtain remained open, leaving the resident in full view of the room. During an interview at the time of the observation, the GNA (Geriatric Nursing Assistant) staff #22 acknowledged that the curtain should have been pulled to ensure privacy during bathing and confirmed it was not done. In an interview with the Director of Nursing on 8/21/25 at 12pm, she stated she was made aware of the findings and had reeducated the GNA on resident rights, including the importance of maintaining privacy during personal care. 2. On 8/21/25 at 11:23 AM, during observation rounds, Resident #93 was observed lying in bed with a urinary catheter drainage bag hanging on the side of the bed. The drainage bag was not covered with a privacy bag and was visible from the hallway to anyone walking by. During an interview conducted on 8/21/25 at 11:28 AM, Registered Nurse (RN) Staff #11 confirmed that catheter drainage bags should be covered with a privacy bag or positioned to ensure they are not visible to others, to protect the residents' dignity. After surveyor intervention, staff #11 placed a privacy bag over Resident #93's urinary catheter drainage bag.

Based on the review of facility-reported incidents, review of pertinent records, and interviews with facility staff and other involved medical staff, it was determined that the facility failed to 1.) protect a resident (#14) from injury while providing care causing the resident to fall out of bed and fracturing a rib, resulting in harm to the resident, 2.) provide appropriate staff support required for toileting and transferring resulting in Resident #214 sustaining a fall with a right femoral neck fracture, resulting in harm to the resident; and 3.) to keep Resident #309 from exiting the building alone and without supervision resulting in harm. This was found to be evident for 3 of 19 residents reviewed for accidents during the facility's annual Medicare/Medicaid survey. The findings include: 1. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Review of MD00193251 on 6/12/23 at 10:00 AM revealed Resident #14 was in the bed and GNA #60 was assisting with a brief change. As GNA #60 walked to the other side of the bed to finish the brief change, the resident rolled over to the other side and fell out of the bed fracturing a rib. On 6/12/23 review of Resident #14 resident's medical records revealed the resident had diagnoses that included cerebral infarction or stroke resulting in hemiplegia and hemiparesis of the left side, generalized muscle weakness and lack of coordination. Review of the Minimum Data Set (MDS) for Resident #14 revealed that in March 2023, the BIMS (Brief Interview for Mental Status) score was an 8 indicating that the resident cognition was moderately impaired. BIMS is a mandatory tool used to screen and identify the cognitive condition of residents. Further review of the MDS section G functional status revealed that for bed mobility, Resident #14 was coded as extensive care with 1 person support. This indicates the resident turns from side-to-side but staff provides weight-bearing support and requires 1 person assist. Review of a nursing note written by Nurse #10 on 6/9/23 at 2 PM revealed a late entry note of the resident's pain assessment. The pain assessment revealed the following: in the last 5 days, he/she has rarely experienced pain, resident now rating pain at 7. On 6/9/21 at 2:30 PM the resident also complained of pain when staff were getting her/him out of bed. The Nurse Practitioner (NP) was made aware and x-rays were ordered. Results of the x-rays were obtained at 4:47 PM results revealed a fracture involving the lateral portion of the left 6th rib with minimal displacement. Further review of the record revealed 2 care plans: Care plan #1 created 9/2/2008 and with revisions dated 6/2/22 for Resident at risk for falls. Care plan #2 dated 1/30/23 revealed Resident had an actual fall, and was at risk for falls related to cognitive loss, lack of safety awareness and impulse disorder. Review of care plan interventions failed to address what to do for the resident's lack of safety awareness and impulse disorder. On 6/12/23 review of the investigation documentation provided by the facility regarding the resident's fall on 6/9/2023 revealed statements from the GNA #60 and Nurse #24. Review of the statements by GNA #60 revealed the following: she entered the resident's room at 6 AM for incontinence care for the resident and in the midst of walking to the other side of the bed to assist the resident, the resident was already en route to turn her/himself. She/he rolled off the bed and GNA #60 asked if the resident was okay then she proceeded to get the assigned nurse so she could assist the resident and assist in helping her/him up. The resident fell on her/his left side. Further review of the statements from Nurse #24 revealed at 6 AM while care was being given to the patient by the assigned GNA, the patient accidentally fell to the floor. The patient was assessed while on the floor, ROM (range of motion) within normal limit v/s (vital signs) were within normal parameters and the patient denied any physical discomfort and the on-call Nurse Practitioner was made aware and no new orders given. On 06/13/23 07:45 AM surveyor observed the resident in bed with floor mats in place and bilateral side rails on the bed. Review of the medical records on 06/13/23 09:26 AM revealed the resident had an order dated 4/19/23 for bilateral side rails. During an interview with the Director of Nursing (DON) on 06/13/23 at 12:36 PM when asked what were the expectations when the GNA is turning a resident to perform incontinence care for the resident, she revealed the expectation is that the side rails are up. During an interview with the DON the surveyor asked why the investigation of the incident failed to identify which side of the bed the resident fell from, what side the resident landed, how the resident was turned, if the side rails were up, or how the resident fell . The DON indicated she must do more investigation. Further review on 06/14/23 09:21 AM of the GNA # a 60's investigation revealed: In the midst of me walking to the other side of the bed to assist the resident, the resident was already in route to turn on [his/her] own and rolled off the bed. During an interview with the rehabilitation director on 06/14/23 at 10:01 AM the surveyor asked if she was familiar with the resident, and she reported that she was. She further reported that each time Resident #14 has a fall, her department evaluates the resident to see if there is anything else that could be done to prevent her/him from falling from a rehab standpoint. During the interview with the rehab director, she revealed that it would be difficult for Resident #14 to pull him/herself over the side rail since his/her left side is paralyzed. During an interview with GNA #60 on 06/14/23 01:36 PM she revealed that the resident was turned towards her which was towards the room door. The surveyor asked how she cleaned the resident when the resident was against her and GNA #60 stated, I was putting a brief under the resident and the bed was wet, so I was changing just the draw sheet. The surveyor asked if that was the correct positioning for cleaning a resident, and she replied, I don't think so. GNA #60 verbalized that the resident turned and that she was not paying attention. When asked by the surveyor if she had the side rails up so the resident could assist her, GNA #60 first reported. I don't remember. When asked if a resident has paralysis should the side rails be used to help them turn GNA #60 said yes. When asked, did you use them? GNA #60 replied, no I did not use them, the resident was already using the headboard [he/she] was still holding the sideboard and [he/she] was rolling off the bed. When asked what GNA #60 could have done to prevent Resident #14 from falling, GNA #60 replied, I could have paid more attention and maybe she/he would not have fallen. The surveyor informed the NHA on 6/15/23 that the fall with fracture resulted in harm to Resident #14 and the NHA verbalized understanding. During the survey exit on 6/20/23 the NHA again was notified of the harm to the resident and all questions regarding the harm were answered. 30440 2. Review of Resident #214's medical record on 6/5/23 at 11:00 AM revealed the resident was admitted with the following but not limited diagnoses: history of falls, difficulty walking and muscle weakness. Review of Resident # 214 MDS on 6/5/23, with assessment reference date (ARD) of 8/20/22 and section G0110 Activities of Daily Living Assistance, was coded (3) extensive assist for transfers, and toilet use. Staff support was coded a (3) requiring two-person physical assist/support. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of resident care. Review of Resident # 214's Activities of Daily Living care plan revealed the resident was dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting and was initiated 5/27/22 with revision 9/30/22. The interventions listed included: Provide extensive assistance of 1 for transfers and toileting. Review of the facility investigation on 6/5/23 at 12:00 PM revealed that on 9/7/22 Resident #214 was assisted from the commode to the wheelchair by Hospice Aide #50. A typed statement provided by Registered Nurse (RN) #17, who was the nurse manager that worked on 9/7/22, indicated that the resident was transferring to the wheelchair from the bathroom on 9/7/22 and the resident missed the seat then squatted down to the floor. The GNA in the next room assisted the resident back to the wheelchair. The resident was examined by the Hospice Nurse #51 and was able to move all extremities, no bruising or swelling noted. Resident #214 did not complain of pain on 9/8/22 or 9/9/22 and was able to turn on own from side to side. An x-ray was ordered on 9/9/22 when the resident had increased pain and guarding of the extremity. Results indicated fractured right hip. Resident #214 was sent to the emergency room for further evaluation and did not return to the facility. The resident had surgery to repair the hip fracture. An interview was conducted with the MDS Coordinator #31 on 6/5/23 at 2:00 PM and she stated that according to the look back period, the resident required 2 persons for assistance twice during that period and was coded at the higher level. MDS Coordinator #31 stated that the care plan was not updated to reflect the resident specific needs or that additional staff was needed for assisting the resident. MDS Coordinator #31 stated that this information was not communicated to the nursing staff at the time of the assessment. An interview was conducted with the Administrator and Registered Nurse (RN) #17 on 6/5/23 at 12:30 PM. They were asked to provide the survey team with an account of the fall that occurred on 9/7/22. They stated the following: On 9/7/22 Resident #214 was transferred from the commode to the wheelchair by Hospice Nurse #51 and the resident missed the seat and fell , squatting to the floor. RN #17 stated that an aide that was next door came over to the resident room to assist Hospice Nurse #51 with returning the resident to the wheelchair. RN #17 was unable to provide the survey team with the nurse assessment of the fall. The Administrator and RN # 17 were able to confirm that the resident was transferred by the hospice nurse #51 and not an aide, which was a discrepancy in their investigation. A phone interview was conducted on 6/6/23 at 9:50 AM with Hospice Nurse #51 and the Hospice Chief Clinical Officer (HCCO) # 70. Hospice Nurse #51 was asked to provide an account of what happened regarding the incident that occurred on 9/7/22 with Resident #214 and she stated the following: She provided care to the resident on 9/7/22 at 1:00 PM. She did a quick assessment of the resident and noted the resident had dyspnea (difficulty breathing) and was placed on oxygen. The resident requested to go to the bathroom, and she assisted the resident to the bathroom. Hospice Nurse #51 further stated that the resident could walk a short distance and could pivot (turn) with assistance. She placed the resident on the edge of the bed, and then stood the resident up and placed the resident in the wheelchair and proceeded to take the resident to the bathroom. The resident stood up, pivoted, and used the commode. After using the bathroom, the resident stood up and their knees buckled, and the resident fell to the floor. Hospice Nurse #51 said she then called for assistance and a GNA who was next door came in. Hospice Nurse #51 stated that she assessed the resident for pain and discomfort, and the resident denied discomfort. The resident was transferred to the wheelchair and then to the bed at that time. Hospice Nurse #51 stated that she did a skin assessment for bruising and swelling after the resident was placed into the bed, of which none was present. Hospice Nurse #51 stated that she reported the incident to the unit nurse, RN #17 what occurred. An interview was conducted with the DON on 6/6/23 at 2:05 PM she stated that the facility nurse should have notified the physician and alerted the DON and the Administrator regarding the resident fall. The DON stated that according to policy, if a report is given to a nurse regarding an incident, specifically, a fall, the nurse is responsible for completing an assessment immediately and the Physician is to be notified. 42782 3. On 06/06/23 4:09 pm, a review of the Facility Reported Incident MD00182639 revealed that on 04/27/22 at 11:15 pm during the assigned Geriatric Nursing Assistant (GNA) shift rounds, Resident #309 was found to be missing from his/her room. The facility staff was unable to locate the resident within the facility. The initial search of the resident did not reveal the location of the resident. An extended exterior search was completed, and the resident was located about 1/2 mile away from the facility. Surveyor review of the clinical revealed that on 04/12/22, Resident #309's Brief Interview for Mental Status Score (BIMS) Score was 9/15, which indicated the resident had moderate cognitive impairment. An Elopement Evaluation that was completed on 04/07/22 documented the resident was unable to ambulate or self-propel a wheelchair independently which was an incorrect assessment as the resident ambulated with a walker based on RN #71's interview. On 06/07/23 at 4:16 pm during an interview with RN #71 concerning the elopement that occurred on 04/27/22 she reported she and three other staff went outside to search for the resident. There was an ambulance near the police station, she stopped and observed Resident #309 on a stretcher shivering and covered with a blanket inside of the ambulance. The resident was identified by RN#71 and the officer reported they received a call from a nearby neighbor that a stranger walking with a walker was knocking at their door. The paramedics reported Resident #309 was outside for a long time, he/she was shivering. The resident was taken to the hospital for further medical evaluation. RN #71 reported the resident was in his/her room at 3 PM, but the staff was unable to provide a time when he/she was last observed in the facility. They were unable to determine how the resident exited the building. A review of Resident #309's hospital Discharge Instructions revealed that the resident was diagnosed with Hypothermia. On 06/08/23 at 2:36 pm during an interview with Administrator #1, she reported after Resident #309's elopement on 04/27/22 a Wander Guard Elopement Device was placed on the resident, Psychiatric services were offered, and staff education was done. [Resident #309] was not being monitored because they thought the wander guard was sufficient to ensure [his/her] safety. On 06/09/23 a review of the Facility Reported Incident (FRI) MD00179934 revealed on the night of 07/03/22, Resident #309 eloped from the facility. The resident's roommate reported to staff that Resident #309 was seen walking down the service hallway. The staff went to the front door which was open and a GNA was coming towards the building from break. GNA #66 reported while driving on [NAME] Lane the resident was seen walking in the direction of the police station. GNA #66 approached the resident and offered them a ride and they returned to the facility. On 06/08/23 at 2:36 pm during an interview with Administrator #1, after the resident eloped on 07/03/22, a 1:1 sitter was assigned to the resident in the evening or late night hours, Psychiatric services were offered, and alternate placement to another facility was initiated.

Based on observations, record revies and interviews of facility staff it was determined the facility failed to: 1.) document that daily activities were provided to residents (Resident # 9 and # 60) and 2.) document medical information in a resident's medical record (Resident #25, #211, #365). This was evident for 5 out of 90 residents reviewed during a facility's annual survey. Findings include, 1. Observations were made of resident # 9 and # 60 on 5/16/23 at 9:55 AM and 5/17/23 at 9:40 AM and there were no activities observed taking place. An interview was conducted with the Recreation Director (RD)# 21 on 5/23/23 at 1:30 PM and she was made aware that no activities were observed for resident # 60 and resident # 9 and asked about specific activities that are done with the residents. She stated that resident # 60's family likes to attend activities in the evening with the resident. She further stated that one on one activities are provided for residents who are unable to attend activities and that documentation is maintained for these activities. On the same date at 2:00 PM RD# 21 provided a copy of the participation record for the residents. Upon review, there were missing entries for the following dates: 5/5/23, 5/6/23, 5/18/23, and 5/21/23. RD# 21 stated that the activities should have been documented and that she will do so moving forward. 42886 2. Review of resident #25's medical records on 5/18/23 at 9:18 am revealed the resident was admitted to the facility on [DATE] for rehabilitation. Review of medical records on 5/18/23 at 9:48 am revealed the resident had a medical certification on 6/15/22 for mental incapacity. Further review of medical records revealed a psychiatric assessment which stated resident #25 had reduced memory recall. During the review of resident #25's medical records, the surveyor was unable to find a diagnosis for the resident's mental incapacity or reduced mental recall. An interview with Social Worker Director #19 and the Director of Nursing on 5/24/23 at 1:08 pm revealed the facility failed to document the diagnosis of vascular dementia in resident #25's medical record. The Director of Nursing stated that she/he made the changes in the medical record after surveyor intervention. 3. Review of facility reported incident MD00188770 reported an allegation that the facility failed to complete resident #211's wound care for two days. Medical record review for resident #211 on 6/5/23 at 11:56 am revealed the resident was admitted to the facility on [DATE] for rehabilitation from a systemic infection. Review of February 2023 treatment administration record (TAR) on 6/5/23 at 12:00 pm revealed missing documentation for wound care orders to cleanse and apply a dressing to the resident's right foot wound on 2/5/23. On 6/5/23 at 1:05 pm, the surveyor interviewed the Administrator and the Director of Nursing (DON) regarding the missing wound dressing change documentation for 2/5/23. The DON admitted the documentation was missing and gave no other information on resident #211. 4. Review of the facility reported incident report MD00187644 reported resident #365 required Narcan administration when he/she was found unresponsive. Medical record review for resident #365 on 5/26/23 at 1:45pm revealed the resident was admitted to the facility on [DATE] for rehabilitation for a right leg fracture. Continued review of resident #365's medical record revealed the resident was administered Narcan for an opiate overdose on 1/10/23. Resident #365 was ordered to have 15 ml Oxycodone every 4 hours for a pain score of 6-10 (resident reporting extreme pain) since 12/22/22. Further review of resident #365's medical record including the January 2023 medication administration record (MAR) and an Oxycodone medication record from 1/1/23 to 1/9/23 revealed that the January 2023 MAR and the Oxycodone medication record contained missing documentation of Oxycodone administrations on 1/2/23 at 11:00 am, 1/4/23 at 11:00 pm, 1/6/23 at 1:35 pm and 1/9/23 at 6:45pm. In interview with the Director of Nursing (DON) on 6/8/23 at 10:11 AM regarding the missing Oxycodone administrations, the DON reviewed the missing Oxycodone administrations and admitted the medication administrations were not documented on the MAR. The DON gave no other information about resident #365's medication administrations.

Based on review of pertinent facility documents and interview with facility staff, it was determined that the facility failed to have a facility assessment that was accurate and complete including information relevant to the needs of the residents the facility serves. The findings include: On 06/20/23 at 11:30 am the surveyor reviewed the Facility Assessment which revealed the Guest Service Director, Assistant Director of Nursing, Admission Director and the Maintenance Director had incorrect names listed and were not the current staff. This was confirmed by the list of key personnel provided by the facility staff. Further review of the provided facility assessment failed to reveal any of the required information related to the numerical staffing needs of the facility based on the facility assessment to ensure enough qualified staff are available to meet each resident's needs. During an interview with the Nursing Home Administrator on 6/20/23 at 11:45 am while reviewing the facility assessment she revealed that it was difficult to understand. She further revealed that the facility is no longer doing the assessment it is being done by Abaqis. Abaqis is a web-based quality management solution that helps long-term care facilities and rehabilitation centers streamline operations related to patient satisfaction management, trend analysis, marketing and more on a centralized platform. During an interview with the NHA on 11/20/23 at 3 PM, the surveyor informed her that the facility failed to address all the required components of this regulation requirement. The NHA revealed that she understood and informed corporate. All concerns regarding the facility assessment were discussed at the survey exit on 6/20/23 at 7 PM.

Based on observations and interviews with facility staff it was determined the facility failed to: 1.) administer medications as ordered by the physician, for 4 of 4 residents (#97, #58, #213, #365) observed during a medication administration and record review; 2.) document a resident (#68) was receiving oxygen therapy and; 3.) document interventions taken when a resident's (#88) tracheostomy tube became dislodged. This was evident for 6 of 6 medical records reviewed for professional nursing documentation during the facility's annual Medicare/Medicaid survey. Findings include: 1a.) A medication observation was made on 6/1/23 at 10:30 AM and Licensed Practical Nurse (LPN) #40 was administering medications to Resident #97. She administered 9:00 AM medications to the resident at 10:30 AM. The computer screen was highlighted pink in color. LPN# 40 explained that when the computer screen highlights a pink screen it means the medications are late. LPN #40 went on to say that a yellow screen appears when the medications are within the normal time frame. LPN #40 explained to the two surveyors that residents' weights were due today and she assisted staff with taking weights and that is why the resident medications were given late. She further stated that she had a large resident load of 22 residents to administer medications to and was in the process of finishing her medication administration. 1b.) Another medication observation was made on 6/1/23 at 10:45 and LPN #40 administered Resident #58's 9:00 AM medications at this time. LPN #40 again acknowledged that the medications were late when the computer screen highlight pink in color. She stated that she would notify the physician. The DON was made aware of all concerns during an interview on the same date at 11:35 AM. 42886 2a.) Review of Facility incident report MD00187644 reported Resident #365 requiring Narcan (medication that reverses opioid overdose symptoms) administration when he/she was found unresponsive. Medical record review for Resident #365 on 5/26/23 at 1:45pm revealed the resident was admitted to the facility on [DATE] for rehabilitation for a right leg fracture. Continued review revealed facility nursing staff administered Narcan to the resident after an opiate overdose on 1/10/23. Resident #365 was ordered to have a 15mg Oxycodone tablet every 4 hours for a pain score of 6-10 as needed (resident reporting extreme pain) since 12/22/22. Further review of resident #365's medical record on 5/26/23 at 2:45pm revealed the January 2023 medication administration record (MAR) for the Oxycodone 15mg tablet order contained several incidents of the resident being administered the medication outside of the parameters of the medication order on the following dates and times: 1/3/23 at 1:30am (pain score = 5), 1/3/23 at 5:59 am (pain score = 5), 1/5/23 at 2:04am (pain score = 0), 1/5/23 at 6:59am (pain score = 0), and 1/9/23 at 6:27am (pain score = 5). Interview with the Director of Nursing (DON) on 6/14/23 at 10:49am regarding the Oxycodone 15mg tablet being administered by facility nursing staff outside of the parameters of the medication order. The DON reviewed the affected Oxycodone administrations and admitted the medication administrations were not administered correctly based on the parameters of the medical order. The DON gave no other information about Resident #365's medication administrations. 2b.) Review of facility incident report MD00184915 reported Resident #213's family reported concerns with medication administration. Medical record review for Resident #213 on 6/6/23 at 9:13am revealed the resident was admitted to the facility on [DATE] for rehabilitation after emergency treatment for difficulty breathing. Continued review of Resident #213's medical record revealed the resident was ordered upon admission a 400 mg Guaifenesin tablet (a medication for coughing) 4 times a day and every 4 hours as needed on 10/16/22. The facility reported the medication delivery was delayed and the facility did not receive the medication until 10/19/22 at 3:41pm. Review of Resident #213's medical record revealed an employee statement dated 10/22/22 which reported on 10/17/22 LPN #72 administered 10ml of Robitussin (cough syrup) to the resident from in-house stock. Review of Resident #213's medical orders did not reveal an order to the administration of 10ml of Robitussin. Continued review of Resident #213's medical records did not find evidence facility nursing staff informed the provider of the delay in the 400 mg Guaifenesin tablet order. An interview with the Director of Nursing (DON) on 6/6/23 at 12:00 pm was held regarding facility nursing staff administering medication to Resident #213 that was not ordered by a provider and failing to inform Resident #213's provider of the delay in the 400mg Guaifenesin tablet order. The DON reviewed the statement by LPN #72, Resident #213's order history, and Resident #213's progress notes. The DON admitted the medication administration of a medication that was not ordered by a provider was prohibited by facility policy. The DON gave no other information about Resident #213's medication administrations or the delay in medication delivery. 42782 3a.) On 05/16/23 at 10:25 am during the initial screening of the residents Resident #68 was observed receiving oxygen therapy 2 liters via nasal cannula. On 05/22/23 at 1:45 pm , a review of Resident #68's electronic medical record revealed an order was written on 08/30/22 for the resident to receive 3 liters of oxygen as needed for shortness of breath (SOB). A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the months of January through May 2023, revealed oxygen therapy was not on the MAR or TAR. On 05/22/23 at 3:17 pm, during an interview with RN #20 he/she reported that Resident #68 had been on oxygen therapy since being admitted to the facility. He/she also reported the resident should be on 2-3 liters of oxygen continuously and if the oxygen is removed the resident's oxygen saturation will decrease. RN #20 made the surveyor aware that the resident's oxygen therapy was documented in the EMR. RN #20 was unable to show the surveyor there was documentation in the EMR that the resident was receiving oxygen therapy. Director of Nursing #2 was made aware the nursing staff had not documented the resident was receiving oxygen therapy consistently for several months. 3b.) On 06/13/23 at 3:42 pm A review of the Change in Condition form related to Resident #88 revealed on 04/11/23 the resident's tracheostomy tube came out and there were no nursing interventions documented on the form. Director of Nursing #2 was made aware. On 06/14/23 9:16 am during an interview with Director of Nursing #2 she verbalized the nursing staff were expected to document what occurred when the resident's tracheostomy tube came out. RN#17 and Unit Manager #33 assisted when the incident happened and should have documented what interventions taken to assist the resident. On 06/14/23 10:35 am during an interview with Unit Manager #33 he/she made the surveyor aware the nursing staff are supposed to do a change in condition when incidents occur and any incident should have an investigation done. Unit Manager#33 indicated that RN #17 came to get him/her for assistance. Resident #88's trach was clearly out, and the Respiratory Therapist was at the bedside. Unit Manager #33 cleaned the tracheostomy site and tried to get the tracheostomy tube back in but was unable to do so. The resident had to go to the hospital for further medical evaluation. Unit Manager #33 verbalized it didn't occur to her to document the course of events. On 06/14/23 10:49 am during an interview with RN#17 she revealed she had worked at the facility for about 3 years and in the past had been the Unit Manager of B wing for over 2.5 years. She revealed when an incident occurs the person in the room that starts the care usually starts the progress note. RN #17 stated she held Resident #88's head for a few minutes, and she may have called 911 but was not sure. She went to Unit A to get Unit Manager #33 who came over to help, then he/she left because there were a lot of people in the room. RN #17 made the surveyor aware he/she didn't think it was necessary to write a note.

Based on observation and interview it was determined that the facility failed to make sure the residents on Unit C had their call bells within reach to call for assistance. This deficient practice was evident in 2 of 4 (#47 & #48) residents observed on Unit C during the annual survey. The findings include: On 05/16/23 at 9:40 am during the initial walk through of the facility, the surveyor observed Resident #48's call bell on the floor and Resident #47's call bell under the bed. LPN #10 confirmed the surveyor's findings at 9:43 am. After surveyor intervention LPN #10 provided both residents with their call bells. On 06/20/23 at 5:47 PM during an interview with LPN #10 he/she stated at the beginning of the shift during rounds the nurses make sure the residents have their call bell. Throughout the day the nursing staff checks to make sure they have their call bells.

Based on medical record and facility investigation review, surveyor interview of facility staff and the complainant, it was evident that the facility failed to provide adequate supervision and assistance during bed mobility for a resident. This resulted in the resident falling from bed, onto the floor, and sustaining a fractured left femur. In addition, the facility failed to consistently provide bed mobility with the assistance of 2 persons for the resident. This was evident for 1 (resident #1) of 4 residents selected for review. The findings included the following: 1. The facility failed to provide adequate supervision and assistance during bed mobility for a resident. This resulted in the resident falling from bed, onto the floor, and sustaining a fractured left femur. On 9/22/15 the office of health care and quality received a complaint, MD 876, regarding resident #1. The complainant alleged that resident#1 had fallen from bed during care and sustained a fractured left femur; the fall was a result of the facility staff providing care for the resident with only one staff person in attendance when 2 were required. On 9/24/15 the surveyor reviewed the complaint intake, resident #1 ' s medical record and the facility investigation as well as interviewed the director of nursing (DON), the administrator (ADM). At 12 noon during an interview with the surveyor the DON confirmed that geriatric nursing assistant (GNA) #1 had repositioned resident #1 in bed alone, there should have been 2 persons available and the resident had fallen out of bed and sustained a fractured femur. The surveyor reviewed resident #1 ' s medical record. On 6/13/15 resident #1 was admitted to the facility following a hospital stay from 4/16/15-6/12/15 following a stay in another long term care facility. The hospital summary [DIAGNOSES REDACTED]. The resident was described to have intermittent moaning cries which were unprovoked. The hospital course was described as complicated . Consultations included intensive care, nephrology, gastroenterology, geriatric and palliative care physicians. The discharge recommendations included complete assistance with all activities of daily living. On 6/13/15, the admission plan of care and physician orders [REDACTED]. On 6/20/15 the admission minimum data set (MDS) 3.0 section G0100 noted that the resident was to receive extensive physical assistance of 2 persons when moved in bed. On 9/15/15 at 9:20pm, per GNA #1 ' s written statement, she had finished bathing resident #1 and started to make the left side of the bed, as she was coming from the left side she noticed the resident falling and tried to prevent the fall by grabbing his/her left arm but was unsuccessful, she fell left knee first to the floor. The GNA provided care which included bed mobility alone. On 9/15/15 at 9:37pm, per the change in condition progress notes, GNA #1 notified nurse #3 that the resident was on the floor. Nurse #3 described resident #1 lying on the floor on his/her left side with a bruise on the left arm. At 9:50pm the physician ordered left knee and hip X-rays because of the fall. On 9/16/15 at 1:31am, the radiology report revealed an oblique fracture of the distal femur with medial and slight posterior angulation; osteopenia and soft tissue swelling. The femur is the thighbone, the distal femur is where the bone flares out like an upside-down funnel just above the knee. An angulated fracture is when the fragments of the bone are at angles to one another. Osteopenia is a condition in which bone mineral density is lower than normal. On 9/16/15 at 1:45am the physician ordered the resident transferred 911 for evaluation. On 9/17/15 at 12:32am there was a late entry on the progress note. In addition to the 911 transfer the physician ordered administration of Tylenol 650mg for possible pain and discomfort. The medics and fire dept arrived and the resident was transferred to the hospital. On 9/17/15, at an undocumented time, GNA #1 was terminated. Per the individual performance improvement plan (termination form), on the evening of 9/15/15 GNA #1 bathed and changed resident #1 in her bed. GNA #1 failed to utilize the assistance of another staff member for bed mobility. While GNA #1 was rolling resident #1 onto her side, the resident slid out of bed onto the floor, which resulted in a fracture of the resident ' s left femur. On 9/25/15 the surveyor received additional information from the DON. She scanned her report to the Maryland Board of Nursing (MBON) regarding GNA#1 and her involvement in the fall and fracture that occurred on 9/15/15. The report noted that GNA #1 failed to utilize the assistance of another staff member to roll a resident over in her bed. While rolling the resident onto her side, the resident slid out of bed onto the floor, which resulted in a fracture to the resident ' s left femur. At 12:50pm the surveyor spoke with the complainant via telephone which confirmed the allegations as written on the intake. According to the complainant the resident had undergone surgical repair of the fracture. The facility failed to provide adequate supervision and assistance during bed mobility for a resident. This resulted in the resident falling from bed, onto the floor, and sustaining a fractured left femur. 2. The facility failed to consistently provide bed mobility with the assistance of 2 persons for the resident. On 9/24/15 at 12pm the DON provided the surveyor with the communication system guidelines that allow the GNAs to determine safe resident handling. This system was based on stickers placed next to the resident ' s name on the outside of the room next to the entrance on the wall. At 1:30pm the surveyor, DON and ADM walked down to the resident ' s room - the notation next to her name was T2 which the DON explained meant that the resident required an ergo slide (a sheet/slide used for repositioning residents) for repositioning and 2 persons. On 9/29/15 at 12:30pm, GNA #1 was interviewed by the surveyor via telephone. She recalled the events of 9/15/15 as noted above. However, she added that she and other GNAs repositioned resident #1 in bed without another GNA ' s assistance and without the use of the ergo slide. She stated that the evening of 9/15/15 was no different. At 1PM, the surveyor reviewed the ADL record for 9/1/15 - 9/15/15, from resident #1 ' s medical record. The area for bed mobility had an area for each shift - night, day and evening. The box for support provided was coded for the number of persons physically assisting the resident. The top box of the resident performance codes noted that there was a split box for recording the highest level of resident performance/ # of times it occurred. The ADL record noted that D indicated that the resident was total dependence - full staff performance during the entire shift (I did everything for the resident who could not help, per the ADL record). The top section noted D consistently with the number of times mobility was preformed below it. For example, D/2 would indicate dependent/done twice. Below that was a box for the number of persons physically assisting. According to the ADL record dated 9/1/15-9/15/15, prior to the fall and fracture (see F323, 1.) On 9/10/15 and 9/11/15, during the night shift, bed mobility was performed 2 times with the assistance of 1 person, instead of 2. The GNA initials appear to be RR . On 9/4/15, during the day shift, bed mobility was performed 2 times with the assistance of 1 person. The GNA initials appear to be KD . On 9/3/15, 9/4/15, 9/6/15, 9/7/15, 9/10/15, 9/11/15, 9/12/15, 9/13/15, 9/14/15 and 9/15/15, during the evening shift, bed mobility was performed 2-3 times/ shift with the assistance of 1 person. The GNA initials appear to be: GNA #1( SH ), DJ , LL , and CK . There were 6 different GNA initials indicating that bed mobility had been provided by 1 person instead of 2 persons on various shifts. 10/15 days on the evening shift noted 1 person assisted with bed mobility instead of 2. On 9/29/15 at 12:45pm during a phone interview with the surveyor the DON and ADM were unable to provide additional information regarding the ADL sheet/record. The facility staff failed to consistently provide bed mobility with the assistance of 2 persons for the resident.